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Dudley Group NHS Foundation Trust

Independent review of allegations made in relation to poor

communication and lack of engagement with clinical staff and

alleged bullying and intimidation by the leadership team

Capsticks Solicitors LLP

35 Newhall Street

Birmingham

B3 3PU

This report has been written for the Chair of Dudley Group NHS

Foundation Trust and NHS Improvement and may not be used,

published or reproduced in any way without their express written

permission.

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This document has been prepared by Capsticks Solicitors LLP for the Chair of

Dudley Group NHS Foundation Trust and NHS Improvement.

This report is confined to those issues that came to our attention during the

course of our investigation.

Capsticks Solicitors LLP has taken reasonable care and skill to ensure that

the information provided in this report is as accurate as possible, based on the

information we have been provided with and documentation reviewed.

However, no warranty is given with regard to the findings or recommendations

contained herein.

No responsibility to any third party is accepted as the report has not been

prepared for any other purpose.

© Capsticks Solicitors LLP

Capsticks Solicitors LLP

35 Newhall Street

Birmingham B3 3PU

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Contents:

Part 1: Executive Summary……………………………………………………...…4

Part 2: Summary of Findings……………………………………………………..14

Part 3: Summary of Recommendations…………………………………………25

Appendix I: Content of anonymous letter………………………………………..28

Appendix II: Terms of Reference………………………………………………...30

Appendix III: Methodology………………………………….……………………..33

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Part 1. Executive summary

1. We have conducted an independent investigation of allegations made in

relation to poor communication and lack of engagement with clinical staff

and alleged bullying and intimidation by the leadership team at Dudley

Group NHS Foundation Trust (the “Trust”) as per the requirements of

the Trust’s Specification.

2. The investigation was commissioned following the receipt of an

anonymous letter (the “Anonymous Letter”) from staff at the Trust

raising concerns about the Trust senior management team.

3. Specifically, we were commissioned by the Trust to review the following

two areas of concern that were raised in the anonymous letter:

i) Trust response to concerns raised regarding poor communication

and lack of engagement with clinical staff by the leadership team.

ii) Cultural / systemic issues and the alleged culture of bullying and

intimidation.

4. Due to the concerns in the letter being raised on an anonymous basis

Capsticks were at no point notified of the identity of the signatories to the

letter and therefore were not aware whether those we interviewed during

the investigation had signed the letter unless they informed us of this at

interview.

5. We adopted the following methodology, further details of which are set

out in Appendix III, in undertaking our investigation:

A desktop review of over 1000 documents obtained from the Trust;

Interviews with 43 Trust staff either in person or by telephone;

Interviews with the 4 Executive Directors of the Trust who were

named in the anonymous letter;

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A series of focus groups with specific staff groups; Non-Executive

Directors and Governors.

6. The Trust provides hospital and adult community services to the

populations of Dudley, significant parts of Sandwell borough and

communities in South Staffordshire and Wyre Forest.

7. The Trust faces significant challenges in respect of the safety,

responsiveness and quality of its services. It has an overall Care Quality

Commission (CQC) rating of “Requires Improvement”. Urgent and

emergency services were rated as “Inadequate” in CQC’s report of April

2018 which followed an unannounced inspection between 4th

December 2017 and 18th January 2018. In addition, CQC has imposed

several conditions on the Trust’s registration pursuant to Section 31 of

the Health and Social Care Act 2008. The findings of this report need to

be viewed in the context of these challenges.

8. During 2017 and 2018 there was a significant turnover of Executive

Directors at the Trust with new appointments made to the posts of Chief

Executive, Medical Director, Chief Nurse, Director of Finance, Chief

Operating Officer and Director of Strategy and Business Planning.

9. We were provided with extensive evidence of the efforts made by the

new Leadership Team to promote improved engagement with staff. In

addition, there was documentary evidence including the Deloitte Well

Led Review and the CQC inspection report of April 2018 indicating that

Trust staff consider that engagement has improved under the current

Executive team. The CQC inspection was based on interviews with a

greater number of Trust staff than participated in this investigation.

10. However, it is clear from our investigation that there are staff within the

Trust who do not feel that they have been engaged effectively by the

current Leadership team. This is apparent from the contents of the

anonymous letter that had 42 signatories and prompted this

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investigation, as well as feedback from some interviewees and some of

the documentary evidence reviewed. It is difficult to assess how

representative these views are of the Trust’s staff as a whole.

11. Effective engagement has also been challenged by the need to comply

with urgent registration requirements imposed on the Trust by CQC.

Whilst we have seen evidence of staff engagement in responding to

CQC requirements, given the tight timescales imposed by CQC it is

understandable that engagement may not have been as widespread as

some may have hoped for.

12. Concerns were also raised in the Non-Executive Director focus group

about the Leadership team’s engagement with staff, and whether the

leadership team was receptive to challenge and the raising of concerns.

13. Engagement with clinical staff was a particular concern that was raised

with us by some interviewees. However, we found that the opportunities

for consultants to influence clinical and operational policy have increased

under the new Leadership Team and that efforts are made to involve the

most appropriate clinicians in decision-making.

14. The Trust is already arranging mediation between its Leadership team

and Consultants and both parties need to play an active part in this if it is

to be successful. As is noted in an Invited Service Review of the Trust’s

adult emergency medicine service by the Royal College of Physicians

(RCP) “Clinical engagement is a two-way process where doctors and

managers need to work together and there are issues here on

both sides.”

15. Although it was suggested that there was limited clinical representation

on the Board, our review found that the clinical representation on the

Trust Board is at least commensurate with the level of such

representation that we would expect to find in Trusts of a similar profile.

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16. The Trust is organised into three clinical divisions and in common with

other similar Trusts has a “Triumvirate” management structure in place in

each of its clinical divisions, comprising a Chief of Service, a Divisional

Chief Nurse and a Divisional Director of Operations.

17. Our investigation suggests that the current “Triumvirate” management

teams have been inconsistent in acting as a bridge between the

Leadership team and frontline staff, which may have contributed to some

staff feeling disengaged with management. We have been told that this

will be addressed when current Chief of Service tenures come to an end

in March 2019 and a new structure and method of remuneration with

additional time and development is put in place.

18. Particular concerns were raised with us about the extent of staff

engagement in the Trust’s response to matters raised during recent

CQC inspections. Whilst it was apparent that some actions needed to be

taken at short notice in order to meet regulatory requirements, we were

satisfied that there had been engagement with staff in respect of these

matters.

19. During the course of our investigation we were told that there had been

limited clinical engagement in respect of several specific service

changes at the Trust, and that this had resulted in poor clinical

governance of those changes. We therefore looked in detail at the

following changes:

The Digital Trust Project;

Changes to the paediatric service in order to provide a 24-hour

emergency service; and

The establishment of the Immediate Admissions Unit (IMAU).

20. We found evidence of clinical engagement in respect of each of these

changes. In the case of the paediatric changes, it was necessary for the

Trust to take immediate action in order to meet CQC requirements, and

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this may have limited the extent of the engagement undertaken. With

regard to the Digital Trust Project, it is apparent that there were

challenges with the delivery of the project but it was clear from the

documentary record that the Board was sighted on these and took steps

to appraise itself as to the risks involved. We did not find poor clinical

governance as a consequence of a lack of engagement in respect of

this programme. In the case of the IMAU, concerns in respect of the

IMAU had originally been identified in an internal Quality and Safety

Review. An action plan had been prepared by the Trust to address

these concerns and the Medical Director had requested further audit

and assurance. However, at the time of the CQC inspection similar

concerns were raised by the inspectors and the unit was closed shortly

afterwards.

21. Concerns were also raised regarding the Trust’s decision to reduce the

Trust’s “core bed base” during the latter part of 2017. Interviewees felt

that this impacted on the Trust’s ability to meet the national A&E “4 hour

wait” target. We were provided with an explanation of why some beds

were closed by the Trust during this period, including reductions in non-

elective length of stay and concerns about Evergreen ward, which was

a ward for patients awaiting transfer to local authority care provision.

Whilst some of these changes were discussed at meetings of the

Medicine and Integrated Care Divisional Management Committee; the

Clinical Quality Safety and Patient Experience Committee (CQSPE) and

the Board it was not clear from our investigation at which of the Trust’s

decision-making forums the decision to reduce bed numbers was

actually taken.

22. Interviewees noted that there had been a significant turnover of

executive Board members during 2017 and 2018. Having considered the

circumstances in which directors left the Trust during this period we did

not find any cause or concern in respect of this turnover.

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23. Some interviewees commented that several members of the new

Leadership team knew each other from previous roles, and questioned

whether appropriate recruitment procedures had been followed in

respect of these appointments.

24. We therefore reviewed the appointment arrangements for all executive

appointments made by the Trust from the date of appointment of the

current Chief Executive. We noted there had been a rapid turnover of

executive directors but did not find any cause for concern in respect of

the departure of directors. With regard to incoming directors, whilst

several directors had either worked together or known each other

previously it was clear that all appointments had been advertised

externally; most had involved an external assessor; and had been made

by both Executive and Non-Executive Directors of the Trust. We were

satisfied that the appointments to the executive team followed

appropriate recruitment procedures.

25. A further concern raised was that the Trust had not addressed evidence

of excess staff workloads, and this had led to an unreasonable approach

to job planning for consultant staff.

26. Many of those we spoke to indicated that staffing was a challenge,

particularly in respect of the Emergency Department. However, it was

clear that the Leadership team was well aware of this issue and actively

addressed staff shortages. Three new Emergency Department

Consultants were appointed in 2017/18 alongside an investment of over

£1.5 million in nursing staff.

27. The Leadership team had prioritised the implementation of formal job

planning, and invested in a software solution to assist with this. We did

not find evidence of unreasonable approaches to job planning being

adopted by the Trust.

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28. There had been discussions with clinicians about the impact of annual

and study leave on the Trust’s performance. A particular issue had been

identified in ophthalmology, following some serious clinical incidents

where patients had suffered significant loss of sight as a result of delays

in follow-up treatment due to the backlog of appointments. The Chief

Executive enquired about the levels of annual leave and study leave that

were being taken, and subsequently met with consultants to seek a

solution. As a result of this meeting, the consultants had agreed to a

phased reduction in study leave and a temporary cessation in other

professional leave.

29. During the course of the investigation we reviewed the Trust’s

processes for raising concerns. The Trust has a Raising Concerns

Speak Up Safely (Whistleblowing) Policy that is broadly consistent with

the policy issued by NHS England and NHS Improvement. The Chief

Executive has overall responsibility for the policy, with the Board

responsible for monitoring compliance. The Trust has appointed

Freedom to Speak Up (FTSU) Guardians as an independent source of

advice to staff. They provide regular reports to the Board. In addition,

there are Freedom to Speak Up Executive and Non-Executive Leads

who are responsible for providing assurance to the Board that the

organisation has an embedded organisation-wide framework for staff to

feel free to speak up and raise concerns. The Non- Executive Lead is

responsible for challenging the Executive Directors for this assurance.

30. Having reviewed the number of concerns raised through the Trust’s

FTSU processes we found that the Trust was not an outlier in respect of

the number of concerns raised when compared with other local Trusts or

available national data. In addition, there was evidence that where

concerns were raised through the FTSU Guardians effective

management action was taken to address those concerns.

31. However, our investigation indicated that some of the Trust’s staff did not

have trust and confidence in these processes for speaking out. Some felt

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that they were not encouraged to speak up, whilst for others this loss of

confidence arose from a perception that the FTSU Guardians were

managerially accountable to the Chief Nurse, and therefore they were

inhibited from raising any concerns relating to the Chief Nurse. As a

consequence, some staff have chosen to raise concerns with the Trust

Chaplaincy Service rather than the FTSU Guardians. The Chaplaincy

Service reports to the Head of Patient Experience who is also

accountable to the Chief Nurse. Despite having weekly meetings with

the Chief Executive and a number of meetings with the Medical Director,

the Chaplaincy Team Leader did not raise these concerns with them.

32. A further concern raised during the investigation was that meetings of

the Joint Local Negotiating Committee (JLNC) had been cancelled

without good reason, and that the JLNC had not been properly involved

in the updating/amendment of some Trust policies. Whilst we found

there was a gap of 9 months between JLNC meetings in 2018, this was

due to the high number of apologies for one meeting, and a diary mix-up

for the next. However, it does appear that certain Trust policies had been

implemented without discussion at the JLNC although some of these

proposed changes were circulated for comment by email prior to

implementation.

33. We do not conclude that that there is a systemic culture of bullying and

intimidation by the Trust leadership. The available data in respect of staff

experiencing harassment and bullying from other staff within the Trust is

below the national benchmark.

34. It was acknowledged by both Executive and Non-Executive Directors

that difficult messages needed to be delivered to the organisation in

order to make the necessary improvements to performance and safety

that were identified by the new Leadership team on appointment, and

also highlighted by CQC during its inspections of the Trust in 2017 and

2018. The need for urgent changes was also contributed to by the

imposition of conditions on the Trust’s CQC registration, which in some

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cases required an immediate response that did not allow for widespread

engagement. However, interviewees told us that the new Leadership

team has adopted a direct management style, which has been described

by some as aggressive.

35. We do, however, consider that given the number of consistent accounts

from those interviewed, there have been instances of behaviour by

members of the Leadership team that were perceived by others as

bullying and harassment. Many of those interviewed made reference to

this alleged behaviour, although the allegations were not supported by

any documentary evidence other than two undated anonymous letters

referred to later in this report.

36. Our terms of reference did not require us to form conclusions on any

individual claims of bullying or harassment; and we do not consider that

there are any specific allegations of bullying and harassment that require

further investigation by the Trust.

37. The two anonymous letters referred to alleged bullying behaviour by the

Chief Nurse. Upon receipt of the first of these letters, the Chief

Executive had a one-to-one discussion with the Chief Nurse but did not

feel that any formal action was required. It is acknowledged in the Trust

Raising Concerns Policy that when concerns are raised anonymously it

can be difficult to investigate them further. The Trust subsequently

confirmed the Chief Nurse as a substantive appointment.

38. We also considered concerns that staff were afraid to report incidents

and that where incidents were reported they were downgraded by the

Leadership team. Our investigation found that the Leadership team had

in fact focussed on improving incident reporting and investigating

incidents promptly although we were told by some interviewees that they

were nevertheless reluctant to report incidents because of fear of

intimidation.

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39. It will be essential in order to rebuild trust and confidence in the Trust’s

formal processes that there is no suggestion that anyone who has

provided information as part of this investigation should be subjected to

any detriment as a consequence.

40. Finally, we were provided with evidence of members of the leadership

team adopting role model behaviour. However, an issue that was raised

with us consistently during the investigation was that members of the

Leadership team had failed to display role model behaviour by regularly

using disabled parking bays when parking at the Russells Hall site.

Members of the Leadership team confirmed that this had occurred,

although they cited some mitigating factors. Nevertheless, it is

unfortunate that the Leadership team provided this poor example to

other staff of the Trust.

41. On the following pages we set out our key findings and

recommendations.

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Part 2. Summary of Findings

Phase 1 - Trust response to concerns raised regarding poor

communication and lack of engagement with clinical staff by the

leadership team.

a) To investigate the allegations that there has been poor

communication and a lack of clinical engagement with clinical staff

where required and to consider whether:

1(a)(i)clinical staff are sufficiently represented and engaged by the

leadership team/s and executives (for example Medical

Director/Director of Nursing), enabling them to be involved

effectively in decision-making

42. Whilst there is evidence of considerable efforts by the new Executive

team to promote greater engagement, it is apparent from the Medical

Engagement survey, the anonymous letter of concerns and some of the

feedback we received from interviewees that some of the Trust’s staff,

including in particular some of the consultant body, do not feel that they

are effectively engaged by the Trust’s leadership.

43. It is difficult for us to judge how widely-held this view is given the limited

number of staff that we interviewed as part of the investigation.

However, the Medical Engagement survey which compared levels of

medical engagement at the Trust with those from a substantial sample

of NHS Trusts indicates that levels of engagement are notably low. We

appreciate that this was the first time that the survey had been

undertaken, and therefore it established a baseline measure of clinical

engagement that may in part be attributable to a long-standing culture.

Whilst the Medical Engagement Survey was discussed at the Executive

Team meeting, Workforce Committee and Clinical Quality, Safety and

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Patient Experience Committee (CQSPE) it does not appear to have

been discussed by the Board in either public or private session.

44. The CQC Inspection Report of April 2018 noted that most staff felt that

communication from the executive team had improved and referred in

particular to the hard work of the Medical Director in trying to engage

medical leaders. The concerns expressed by some of those we

interviewed about the lack of clinical engagement are therefore not

shared by all staff.

45. It should be noted that despite the numerous groups and/or

opportunities that the Chief Executive, Medical Director, Director of

Governance and others identified as modes of engagement, there

clearly remain some staff within the Trust who do not feel that the

Leadership team is engaging effectively with them. It should be

emphasised that this view is not limited to staff in the Trust’s Emergency

Department. The need for improved staff engagement was recognised

by the Trust in its response to the 2017 national Staff Survey. An action

plan was developed and approved by the Board in July 2018.

46. We acknowledge, as reported by the Invited Service Review in respect

of adult emergency medicine that engagement is a two-way process,

and clinical and other staff share responsibility with the Leadership team

for achieving improved engagement.

47. The perceived lack of engagement is in our view exacerbated by an

inconsistent approach to engagement within the clinical divisions, and

through each division’s triumvirate structure.

48. Engagement has also been compromised by the need to comply with

urgent registration requirements imposed on the Trust by CQC. Whilst

we have seen evidence of attempts to engage clinical staff in

developing action plans in response to these requirements, given the

tight timescales imposed by CQC it is understandable that engagement

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may not have been as widespread and considered as some may have

hoped for.

49. With respect to the concern around clinical representation on the

Executive Board, we find that the clinical representation is at least

commensurate with the level of clinical representation that would be

found elsewhere in Trusts of a similar size.

1(a)(ii) because of the failure to engage clinical teams, there is poor

clinical governance of engagement in change and operational

policy, including any undue reliance on external consultants

50. Some changes have been made in respect of clinical services with

limited clinical engagement. On occasion this has been due to the need

to take immediate action in order to comply with CQC registration

requirements. Of these changes, the decision to open the IMAU was

subsequently reversed following concerns raised by CQC. Similar

concerns had initially been identified by an internal Quality and Safety

Review several weeks earlier. An action plan had been prepared to

address these concerns and the Medical Director had requested further

audit and assurance.

51. We do not consider that there has been undue reliance on external

consultants. Where external consultants have been engaged this has

reflected the limited internal management capacity to take on the

projects concerned. However, on the basis of comments from some of

those interviewed we feel that the use of external consultants may have

contributed to the feeling on the part of some staff that they had not

been engaged, particularly where there has been limited explanation as

to why these external consultants have been brought in, and what the

outputs of their consultancy work have been. By way of example,

several interviewees expressed the view that there had been a lack of

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communication about the introduction of external consultants FourEyes

to undertake work in the Trust.

1(a) (iii) the quality and financial impact assessment undertaken for

significant service changes since April 2017 involved all

appropriate stakeholders; there is evidence of appropriate learning

and adaptation because of that involvement

52. It is clear from the various minutes that we have reviewed that a range

of stakeholders were involved in decision-making in respect of proposed

service changes, although these minutes do not generally evidence the

extent of stakeholder involvement in the development of the various

proposals.

1(a)(iv) the Trust’s approach to the management of organisational

change, included the line of sight through to the Board and Council

of Governors and whether the associated policies and procedures

were followed when implementing any significant changes or

appointments

53. Whilst we acknowledge that it may have appeared to some within the

Trust that there had been a rapid turnover of executive directors, on the

basis of the evidence that we have considered we do not find any cause

for concern in respect of the departure of directors.

54. Some of those appointed to the Leadership team were known to the

Chief Executive prior to their appointment, and this may have

contributed to a perception on the part of some staff that the Chief

Executive had appointed acquaintances and former colleagues to key

director roles and that those appointees would therefore be unlikely to

question her decisions and leadership style. We are, however, satisfied

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that the appointments to the executive team following the Chief

Executive’s appointment in April 2017 followed appropriate recruitment

procedures.

1(a)(v) there was a failure to act on evidence of excess workload of

different staff groups, because of either system or other changes

leading to unreasonable approaches to job planning

55. We did not find that there was a failure to act on evidence of excess

workload of different staff groups. On the contrary, the new Executive

team was well aware of this issue and the documentary record indicates

that they actively addressed staff shortages within the Trust.

56. We also did not find evidence of unreasonable approaches to job

planning. Historically, there had been very low take-up of formal job

planning within the Trust and the steps taken to address this appear to

us to have been reasonable.

1(a)(vi) the trust has in place the appropriate and robust channels for

staff to feedback any concerns they have regarding organisational

change, service change or patient safety; the trust has responded

to those concerns at all levels including executive, Board and

Council of Governors

57. The Trust has appropriate channels for staff to feedback any concerns

they have, and there is evidence that when concerns have been raised

through these channels they have been responded to at appropriate

levels, including by the Chief Executive. The available data indicates

that the raising of concerns through the Trust’s Freedom to Speak Up

(FTSU) processes are in line with local and national norms.

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58. However, we are concerned that these channels are not regarded by

some staff as being robust and reliable, and have been bypassed on

some occasions, with staff preferring to raise their concerns with the

Chaplaincy service or by writing anonymous letters.

59. It is unfortunate that during a period of major change and challenge for

the Trust JLNC meetings did not occur for a period of approximately 9

months, and that some changes to policies were introduced without

discussion at JLNC meetings. We acknowledge that there were genuine

reasons for the cancellation of the meetings. In addition, some of the

proposed changes to policies were circulated for comment by email

prior to implementation.

1(a)(vii) there has been engagement with clinical staff regarding the

management of CQC requirements, resulting from their inspections

60. We find that there has been engagement with clinical staff regarding the

management of CQC requirements even where those requirements

have required an immediate response. It is hoped that as the urgency of

CQC requirements reduces, there will be more time available for the

Trust leadership to engage more comprehensively with those that do

not feel they have been engaged effectively in response to CQC’s

requirements to date. There is also a need for senior staff in the

Emergency Department in particular to engage more effectively in

respect of the required standards of quality and safety.

Phase 2 - Cultural / systemic issues and the alleged culture of bullying

and intimidation.

a) To investigate the allegations that there is a culture of widespread

bullying and intimidation of staff. To consider whether:

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2(a) (i) there have already been incidents since April 2017 of bullying and

intimidation reported through the trusts current processes and

there is evidence of appropriate learning and adaptation because of

that reporting

61. There have been incidents since April 2017 of bullying and intimidation

reported through the Trust’s current processes. We note that these

incidents have been considered further by the executive team. Some of

the matters were referred to the HR department and all were resolved

without any requirement for a formal investigation. Without further detail

of the incidents in question we are unable to say whether this was an

appropriate response.

2(a)(ii) there is evidence of widespread bullying and intimidation of staff

by executives, and other senior staff at the trust, and whether any

specific allegations of such bullying and harassment require

further investigation

62. A number of allegations have been made of behaviour perceived as

bullying and intimidation of staff by members of the Leadership team.

These allegations have not been substantiated, although we received

similar accounts of this behaviour from a number of those interviewed.

63. Our terms of reference did not require us to form conclusions on any

individual claims of bullying or harassment, but to identify any broad

areas of concern and draw attention to any cases that do not appear to

have been properly investigated through the trust’s own procedures. We

do not consider that any specific allegations of bullying and harassment

were raised during our investigation that require further investigation.

64. A number of allegations of bullying and intimidation of staff, primarily by

the Chief Nurse but also by the Medical Director, were raised with us.

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Both the Chief Nurse and Medical Director refuted these allegations.

The allegations have not been subject to any investigation within the

Trust and insufficient detail has been provided in most cases to enable

any further investigation of the allegations to be made. Where some

details have been provided our further enquiries have not identified any

specific allegations that require further investigation by the Trust. It was

in any event beyond the scope of our terms of reference to investigate

specific allegations.

65. We were also provided with a letter from a member of staff who had left

the Trust and who said that she had raised allegations of bullying and

harassment by her line manager and others and stated that “one thing I

have found to my detriment is that if you’re in high places you can be

untouchable”. This member of staff indicated that no action was taken in

response to the concerns she raised although her letter did not indicate

who she had raised her concerns with.

2(a)(iii) there is evidence that staff are afraid to report incidents,

incidents being downgraded and that patient safety concerns are

minimised

66. Whilst there has been a drive from the leadership team to close down

incidents, the documentation that we have reviewed suggests that this

has been in an effort to comply with the prescribed timescales for the

reporting and analysis of those incidents rather than in order to

suppress information. The leadership team has focussed on

encouraging a reporting culture within the Trust, and we do not find that

there have been attempts to minimise reporting of patient safety

concerns.

67. We are however concerned on the basis of comments made by some of

those interviewed that there may be staff who are afraid to report

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adverse incidents and that this is consistent with evidence we heard of

staff being afraid to use the Trust’s formal Speak Up processes.

2(a)(iv) there is evidence that staff do not trust the effectiveness of (and

therefore are not using) the Trust’s own bullying and harassment or

whistleblowing policies

68. There is evidence that some staff do not trust the effectiveness of the

Trust’s bullying and harassment or whistleblowing policies and therefore

are not using them. We were told that a number of people have

approached the chaplaincy service instead of going through the

established channels for raising concerns.

2(a)(v) the Trust has taken sufficient steps to ensure that the leadership

team display role model behaviour

69. We did receive evidence that members of the leadership team display

role model behaviours, and that this has been recognised both within

the Trust and externally. One issue raised with us was of members of

the Leadership team inappropriately parking in disabled parking bays.

Whilst we noted there were some mitigations for this behaviour it was

frequently cited by interviewees as an example of members of the

Leadership team not acting as role models.

70. In addition, Non-Executive Directors of the Trust reported that Executive

behaviour was not promoting a positive culture within the Trust, and that

challenge was not encouraged by the Executive team.

2(a) (vi) the Trust’s leadership has taken steps to deliver a positive

change to its speaking up culture

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71. We conclude that the Trust leadership has sought to promote a

speaking up culture and there is evidence that the number of concerns

raised under the Freedom to Speak Up process has increased under

the current Leadership team and is in line with local comparators.

However, some staff believe that this is a superficial approach and do

not have trust and confidence in the Trust’s formal processes.

2(a) (vii) the Board has assessed the impact of the significant turnover

in executive and senior management and clinical leadership at

trust; and what risk assessment and mitigations it has put in place

for current and future possible changes

72. Our enquiries satisfied us that appropriate recruitment processes were

followed for all Executive appointments.

73. The Trust has invested in significant leadership development in order to

strengthen its leadership capacity in line with the recommendations in

the Deloitte Well Led Review. In addition to a Board Development

programme the Trust has implemented an Executive Team

Development Programme and a further development programme aimed

at the divisional leadership teams.

2(a) (viii) the existing board development could be helpfully enhanced

around the perceived dynamics between the leadership and the

staff.

74. There were mixed views as to whether Board development could

address the perceived dynamics between leadership and staff. Some felt

that the relationship between the Leadership team and some clinicians

24

had broken down irretrievably. Others considered that relationships were

potentially salvageable but that this would be challenging and would

require much greater visibility and engagement on the part of the

leadership team.

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Part 3. Summary of recommendations

75. We make the following recommendations in respect of Phase 1 of the

investigation - Trust response to concerns raised regarding poor

communication and lack of engagement with clinical staff by the

leadership team.

i. As a priority, Trust leadership and consultants should proceed with

the planned mediation process.

ii. For the Trust Leadership to develop a programme to achieve

effective engagement with all staff, focussing on the development

of a more inclusive and listening culture.

iii. The consultant body to actively engage with the Trust leadership

recognising the 2-way nature of effective engagement.

iv. The Medical Engagement Survey should be repeated in May 2019

and the Trust Board should receive the results of the survey and

compare these with the results from May 2018.

v. To review the operation of the Triumvirate structure across the

Trust’s clinical divisions with a view to promoting consistent and

effective engagement through the Triumvirates and to assess

whether the membership of the triumvirates needs to be refreshed.

vi. To review the governance arrangements for engagement and

decision making around service changes. In future, such decisions

should be fully-documented, and it should also be clear what the

appropriate decision-making forum is, and, if this is not the Board,

how this forum will report in to the Board.

vii. To adopt the recommendations of the Invited Service Review in

respect of Paediatrics if they have not already been implemented.

viii. To review the Freedom to Speak Up arrangements within the Trust

in order to increase staff trust and confidence in those

arrangements, including in particular ensuring that the FTSU

Guardians are, and are seen to be, impartial and not capable of

26

being unduly influenced by any member of the Trust leadership

team.

ix. To ensure that meetings of the JLNC take place on a regular basis

and that the JLNC’s role in reviewing policy changes is agreed, and

observed consistently.

76. We make the following recommendations in respect of Phase 2 of the

investigation - Cultural / systemic issues and the alleged culture of

bullying and intimidation.

i. To ensure that where incidents of bullying and harassment are

raised through the Trust’s processes these are reviewed at an

appropriate level within the Trust to ensure that there is appropriate

learning and adaptation even if no formal action is taken in

response to the incidents.

ii. To consider as a matter of urgency how the Trust can increase

staff confidence in its existing processes for raising concerns and

whistleblowing.

iii. To reaffirm the Trust’s commitment to the values of the national

FTSU policy and review the wording of its FTSU policy to consider

whether this should more closely follow the national framework.

iv. To agree a protocol with the Chaplaincy Team about how it will

report concerns in respect of bullying and harassment in order to

enable effective action to be taken in response to those concerns.

v. To review the Trust’s Board Development programme in the light of

the findings of this investigation as a matter of urgency in order to

incorporate into that programme:

a. The importance of Trust directors acting as role-models for

the organisation;

b. Reflection by the Leadership team on the manner of their

response to challenge and their overall approach to

management;

27

c. The importance of Non-Executive Directors feeling

empowered to challenge Executive colleagues effectively;

d. More effective engagement between the Trust leadership and

its staff.

vi. To review and if appropriate refresh the Trust’s development

programmes for the Executive Team and divisional leaders in the

light of the findings of this investigation.

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Appendix I

Text of letter of concerns from Trust Consultants

Concerns about the executive management team of Dudley Group NHS

Foundation Trust.

We, the undersigned, are writing to raise concerns about the senior

management team at Dudley Group NHS Foundation Trust - specifically

Diane Wake (Chief Executive), Siobhan Jordan (Chief Nurse), Andrew

McMenemy (Head of HR) and Julian Hobbs (Medical Director).

Following the appointment of Diane Wake as CEO, there were a number of

resignations from the executive board, some at very short notice, which

affected the continuity and experience of the team. Subsequently, there has

been a significant deterioration in leadership style. Individual members or

groups of staff are increasingly blamed for systematic failings. A culture of

bullying and intimidation has rapidly developed, where staff are afraid to raise

concerns in case they are scapegoated. This is having a very negative effect

on staff morale, patient care and the safety agenda.

There have been a number of concerns raised regarding the Consultant job

planning process. Changes to this process have not been developed in

partnership with the JLNC as in previous years, and the approach has been

very heavy-handed. Individual teams are being asked to work to completely

unreasonable job plans. The workload of many members of the medical

workforce is now unsustainable and a number of consultants have resigned

from leadership positions and even their clinical roles.

The opportunities for consultants to influence clinical and operational policy

changes has been curtailed. Instead of encouraging dialogue and partnership,

the senior executive team is reactive, and inward-looking. In all areas of

clinical policy, there is undue reliance on arms-length written reports, which

have become an overwhelming burden for staff to submit. Whilst we welcome

insight and challenge from clinical experts, there is now an over-reliance on

advice from costly external management consultants. Moreover, these

external reports are not always shared with clinical teams in a timely manner,

29

particularly those that are critical of corporate management. As a result of the

failure to engage clinical teams, there is poor clinical governance of changes

in clinical processes, without always considering the wider impacts. This was

noted in the recent CQC inspection.

There has been a striking deterioration in the clinical and financial

performance of the Trust which we hold the current senior management team

responsible and accountable for. The Trust is underperforming in key clinical

performance indicators, such as the 4 hour target. The Trust failed to manage

winter pressures as well as in previous years, resulting in poor patient

experience and an extremely challenging working environment for clinicians,

and there is little evidence of robust plans for the coming winter. The recent

CQC inspection identified a number of priorities to address, but there has

been an incoherent strategy and poor engagement with staff to respond to

these concerns. The executive team have not taken any responsibility for their

role in the deterioration in Trust performance indicators. The financial position

has deteriorated sharply, and the recovery plan, to deliver £20 million CIP in

the context of failing clinical performance, is unachievable.

We no longer have confidence in the executive director team to deliver the

leadership that the Trust needs. We urge you to step in to ensure the proper

management of the Trust for the sake of our patients and the clinical teams

who care for them.

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Appendix II

Terms of Reference

Dudley Group NHS Foundation Trust (DGFT) whistleblowing concerns -

scope for investigation

The investigation itself will need to be conducted in such a way as to give

confidence to staff that their views will be heard. It will be conducted in such a

way that will maintain confidentiality of individuals where necessary and

appropriate to avoid the opportunity for repercussions on them. The

investigation will be commissioned by the trust, with terms of reference that

are agreed by NHSI and NHSI will be a joint recipient of the report.

The objective is to undertake an independent investigation of allegations

raised by an anonymous group of consultants at DGFT, with a specific focus

on the following areas:

Phase 1 – Trust response to concerns raised regarding poor

communication and lack of engagement with clinical staff by the

leadership team.

a) To investigate the allegations that there has been poor communication

and a lack of clinical engagement with clinical staff where required and

to consider whether:

i) clinical staff are sufficiently represented and engaged by the

leadership team/s and executives (for example Medical

Director/Director of Nursing), enabling them to be involved

effectively in decision-making

ii) because of the failure to engage clinical teams, there is poor

clinical governance of engagement in change and operational

policy, including any undue reliance on external consultants

iii) the quality and financial impact assessment undertaken for

significant service changes since April 2017 involved all

31

appropriate stakeholders; there is evidence of appropriate

learning and adaptation because of that involvement

iv) the Trust’s approach to the management of organisational change,

included the line of sight through to the Board and Council of

Governors and whether the associated policies and procedures

were followed when implementing any significant changes or

appointments

v) there was a failure to act on evidence of excess workload of

different staff groups, because of either system or other changes

leading to unreasonable approaches to job planning

vi) the trust has in place the appropriate and robust channels for staff

to feedback any concerns they have regarding organisational

change, service change or patient safety; the trust has responded

to those concerns at all levels including executive, Board and

Council of Governors

vii) there has been engagement with clinical staff regarding the

management of CQC requirements, resulting from their

inspections

b) To make any recommendations in the light of the findings in relation to

the matters above, including any proposals for further action to the

taken by the trust, with findings to be shared with NHSI and the Trust

Chair being the joint recipients of this work.

Phase 2 - Cultural / systemic issues and the alleged culture of bullying

and intimidation.

a) To investigate the allegations that there is a culture of widespread

bullying and intimidation of staff*. To consider whether:

i) there have already been incidents since April 2017 of bullying and

intimidation reported through the trusts current processes and

there is evidence of appropriate learning and adaptation because

of that reporting

32

ii) there is evidence of widespread bullying and intimidation of staff

by executives, and other senior staff at the trust, and whether any

specific allegations of such bullying and harassment require

further investigation

iii) there is evidence that staff are afraid to report incidents, incidents

being downgraded and that patient safety concerns are minimised

iv) there is evidence that staff do not trust the effectiveness of (and

therefore are not using) the trust’s own bullying and harassment

or whistleblowing policies

v) the trust has taken sufficient steps to ensure that the leadership

team display role model behaviour

vi) the trust’s leadership has taken steps to deliver a positive change

to its speaking up culture

vii) the Board has assessed the impact of the significant turnover in

executive and senior management and clinical leadership at trust;

and what risk assessment and mitigations it has put in place for

current and future possible changes

viii) the existing board development could be helpfully enhanced

around the perceived dynamics between the leadership and the

staff.

* We are not required to form conclusions on any individual claims of bullying

or harassment, but should identify any broad areas of concern and draw

attention to any cases that do not appear to have been properly investigated

through the trust’s own procedures.

b) To make any recommendations in the light of the findings in relation to

the matters above, including any proposals for further action to the

taken by the Trust. NHSI and the Trust Chair being the joint recipients

of this work.

33

Appendix III

Methodology

On 13 August 2018 Capsticks Solicitors LLP was commissioned by the Trust

Chair to conduct an investigation into the concerns raised in the Letter.

These concerns were consolidated into the Terms of Reference (the

“Terms”), which are set out in Appendix II.

Due to the concerns in the Letter being raised on an anonymous basis

Capsticks were at no point notified of the identity of the signatories to the

Letter and therefore were not aware whether those we interviewed during the

investigation had signed the Letter unless they informed us of this at

interview.

The Investigative Team comprised Peter Edwards and Bridget Prosser,

Partners, and David True, solicitor.

The Investigative Team were also supported by Ian Anderson, who has

worked as a Director of Human Resources in the NHS and the private sector

as well as serving as a Non-Executive Director of several companies. He

facilitated the focus groups that were made available to members of the

Trust.

Over one thousand separate documents, comprising several thousand pages

in total, have been received and considered as a part of the investigatory

process. Only those documents considered material have been explicitly

referred to within the body of this report.

Each Named Executive confirmed that they wished to be involved in the

investigation and therefore members of the Investigative Team carried out

interviews with each of them.

34

The initial interviews with each of the Named Executives lasted between 3

and 5 hours, depending on their availability and the nature, content and

number of questions being asked. Where it was apparent that not all issues

had been dealt with during the first interview then a second interview was

subsequently scheduled and took place.

In late August 2018 an announcement was made on the Trust’s intranet that

explained why the investigation had been commissioned along with how

Trust employees could get involved if they wished to do so, providing a

deadline of 12 September 2018 for any responses to be provided. A specific

Capsticks email account was created to allow Trust employees to contact the

Investigative Team.

Although Trust employees had initially been given until 12 September 2018

to request an interview with a member of the Investigatory Team, it was

agreed by the Investigation Recipients that this deadline should be extended

to allow more employees to engage with the process where possible.

Over a period of two weeks, from 10 September 2018 until 21 September

2018, members of the Investigative Team met or spoke with 31 Trust

employees on a one to one basis. These interviews lasted between one and

two hours, with only one or two exceptions.

Despite the passing of the extended deadline imposed by the Investigation

Recipients, Trust employees continued to request interviews with the

Investigatory Team. The Trust Chair and NHS Improvement authorised a

further extension of time for those who had missed the original deadline and

a further 12 employees were interviewed on a one-to-one basis, either in

person or over the phone, during this period.

At the commencement of each interview the individual was introduced to the

investigator, provided with a brief background as to how the investigation had

come about, notified that the interview was being recorded but that the

recording would not be provided to the Investigation Recipients and was to

35

be used solely as an aide memoire by the Investigative Team, and informed

that they had the right to remain anonymous throughout the process and

within the report if they so wished. The investigator took this opportunity to

draw to the interviewee’s attention the fact that if they provided information

that was so specific to that individual that it may identify them then their

anonymity would be at risk if it was included within the report. The

investigator clarified that if such information was provided and the

investigator thought that this may be included in the investigation report this

would be discussed with the interviewee during the interview or, alternatively,

the investigator would contact the interviewee to discuss the matter further

when drafting the investigation report.

At the same time that the one-to-one interviews were being arranged

employees were given the opportunity to request involvement in role-specific

focus groups as an alternative to an interview.

While a number of employees expressed an interest in attending both a one-

to-one interview and a focus group, it was agreed between the Investigative

Team and the Investigation Recipients that this would not be appropriate in

order to ensure that there was no over-representation of any individual’s

viewpoint when the information was collated and the report prepared.

In accordance with the principles of fairness each Named Executive was

provided with a copy of relevant extracts from the draft report for their review

and comment prior to the completion of the report and its submission to the

Trust Chair and NHS Improvement.